Cardiac Perforation Caused By Pectus Excavatum Metal Bar Stabilizer: A Case Report.

This paper reports the case of a female patient who underwent minimally invasive repair of pectus excavatum (MIRPE) in another service that evolved with bar rotation and cardiac perforation caused by the left stabilizer. The unique and frightening aspect of the case is that despite having the stabilizer inside the ventricle, the patient was oligosymptomatic: occasional chest pain and respiratory discomfort. Preoperative imaging showed rotation of the bar with stabilizers within the thoracic cavity. During surgery, intense ossification was observed around the prosthesis and it was noted that the left stabilizer had perforated the patient's left ventricle. Cardiac repair required a Clamshell incision and cardiopulmonary bypass. This case reinforces the validity of late radiological follow-up after MIRPE in an attempt to avoid this type of event, and the need to reevaluate the use of stabilizers perpendicular to the bar since they are not safe to prevent rotation of these implants.

The The Sandwich Technique For Minimally Invasive Repair Of Pectus Carinatum.

INTRODUCTION: Minimally invasive repair of pectus carinatum (MIRPC) has been performed using the Abramson technique in which the bar that compresses the sternum is fixed with steel wires on the ribs. A 14-year-old patient underwent to a MIRPC using a sandwich technique in which two metallic bars fixed with bridges were implanted below the sternum under thoracoscopic vision, and another bar in a subcutaneous tunnel was implanted above. This technique has the potential to avoid specific problems related to the original technique like loosening of support for correction (broken wire), avoidance of induction of pectus excavatum or subcutaneous tissue adhesion.

Randomized comparison of oblique and perpendicular stabilizers for minimally invasive repair of pectus excavatum.

OBJECTIVES: Bar dislocation is one of the most feared complications of the minimally invasive repair of pectus excavatum. METHODS: Prospective randomized parallel-group clinical trial intending to assess whether oblique stabilizers can reduce bar displacement in comparison with regular stabilizers used in minimally invasive repair of pectus excavatum. Additionally, we evaluated pain, quality of life and other postoperative complications. Participants were randomly assigned to surgery with perpendicular (n = 16) or oblique stabilizers (n = 14) between October 2017 and September 2018 and followed for 3 years. Bar displacements were evaluated with the bar displacement index. Pain scores were evaluated through visual analogue scale and quality of life through the Pectus Excavatum Evaluation Questionnaire. RESULTS: Control group average displacement index was 17.7 (±26.7) and intervention group average displacement index was 8.2 (±10.9). There was 1 reoperation in each group that required correction with 2 bars. Bar displacement was similar among groups (P = 0.12). No other complications were recorded. There was no statistically significant difference on pain score. There was a significant difference between pre- and postoperative composite scores of the participants' body image domain and psycho-social aspects in both groups. The difference between the pre- and postoperative participants' perception of physical difficulties was greater and statistically significant in the intervention group. CONCLUSIONS: There was no statistical difference in the use of perpendicular or oblique stabilizers, but the availability of different models of stabilizers during the study suggested that this can be advantageous. The trial is registered at ClinicalTrials.gov, number NCT03087734.

Cohort study on 20 years' experience of bilateral video-assisted thoracic sympathectomy (VATS) for treatment of hyperhidrosis in 2431 patients.

BACKGROUND: Primary hyperhidrosis is a condition characterized by excessive sweating, inconsistent with the needs for thermoregulation. OBJECTIVE: To assess the effectiveness and the change in the quality of life of patients undergoing bilateral VATS (video-assisted thoracoscopic sympathectomy) for treatment of hyperhidrosis, in a large case series. DESIGN AND SETTING: Cohort study conducted in a tertiary hospital specializing in hyperhidrosis located in São Paulo, Brazil. METHODS: A total of 2,431 patients who underwent surgery consisting of bilateral video-assisted thoracoscopic sympathectomy between January 2000 and February 2017 were retrospectively assessed in an outpatient clinic specializing in hyperhidrosis. The patients underwent clinical and quality of life assessments on two occasions: firstly, prior to surgery, and subsequently, one month after the operation. The presence or absence of compensatory hyperhidrosis (CH) and general satisfaction after the first postoperative month were also evaluated. RESULTS: All the patients operated had poor or very poor quality of life before surgery. In the postoperative period, an improvement in the quality of life was observed in more than 90% of the patients. Only 10.7% of the patients did not present CH, and severe CH occurred in 22.1% of the patients in this sample. CONCLUSION: Bilateral VATS is a therapeutic method that decreases the degree of sweating more than 90% of patients with palmar and axillary hyperhidrosis. It improves the quality of life for more than 90% of the patients, at the expense of development of CH in approximately 90% of the patients, but not intensely.

Cohort study on 20 years' experience of bilateral video-assisted thoracic sympathectomy (VATS) for treatment of hyperhidrosis in 2431 patients

Abstract BACKGROUND: Primary hyperhidrosis is a condition characterized by excessive sweating, inconsistent with the needs for thermoregulation. OBJECTIVE: To assess the effectiveness and the change in the quality of life of patients undergoing bilateral VATS (video-assisted thoracoscopic sympathectomy) for treatment of hyperhidrosis, in a large case series. DESIGN AND SETTING: Cohort study conducted in a tertiary hospital specializing in hyperhidrosis located in São Paulo, Brazil. METHODS: A total of 2,431 patients who underwent surgery consisting of bilateral video-assisted thoracoscopic sympathectomy between January 2000 and February 2017 were retrospectively assessed in an outpatient clinic specializing in hyperhidrosis. The patients underwent clinical and quality of life assessments on two occasions: firstly, prior to surgery, and subsequently, one month after the operation. The presence or absence of compensatory hyperhidrosis (CH) and general satisfaction after the first postoperative month were also evaluated. RESULTS: All the patients operated had poor or very poor quality of life before surgery. In the postoperative period, an improvement in the quality of life was observed in more than 90% of the patients. Only 10.7% of the patients did not present CH, and severe CH occurred in 22.1% of the patients in this sample. CONCLUSION: Bilateral VATS is a therapeutic method that decreases the degree of sweating more than 90% of patients with palmar and axillary hyperhidrosis. It improves the quality of life for more than 90% of the patients, at the expense of development of CH in approximately 90% of the patients, but not intensely.

Evaluation of compensatory hyperhidrosis after sympathectomy: The use of an objective method.

OBJECTIVE: To investigate the prevalence of compensatory hyperhidrosis following videothoracic sympathectomy to treat palmoplantar hyperhidrosis and its effect on sweating in the chest, abdomen, back and thighs. Furthermore, to evaluate the concordance between a subjective and an objective method of assessment for compensatory hyperhidrosis. METHODS: Forty patients with combined palmar and plantar hyperhidrosis who underwent video-assisted thoracoscopic sympathectomy (15 women and 25 men, with a mean age of 25 years) were prospectively followed for 1 year. Subjective and objective parameters were evaluated, using respectively a questionnaire and a sudorometer (Vapometer). RESULTS: In the subjective analysis, in the first month, only 10% of patients did not have compensatory hyperhidrosis, and 70% continued to report it at 1 or more sites after 1 year. In the objective analysis, 35% of the patients did not present compensatory hyperhidrosis after 1 month, and this number persisted stable, with 30% of patients remaining free of compensatory hyperhidrosis after 1 year. The most frequent area affected by compensatory hyperhidrosis was the back in both assessments. There was no positive concordance between the results of the objective and subjective analysis at any time in any of the 4 regions studied. CONCLUSIONS: Compensatory hyperhidrosis is a very common postoperative side effect after videothoracic sympathectomy, occurring early after the procedure and persisting for prolonged periods of time. The most frequently affected body area is the back, and no concordance between objective and subjective assessments was observed.

Quality of life outcomes after minimally invasive repair of pectus excavatum utilizing a new set of metallic bars and stabilizers.

BACKGROUND/PURPOSE: The aim of the study was to evaluate the postoperative quality of life (QoL) of patients who underwent minimally invasive repair of pectus excavatum (MIRPE) with a newly designed bar and bar stabilizers. METHODS: We conducted a prospective randomized study in which patients were operated either with standard perpendicular stabilizers (control group) or with the newly designed oblique stabilizers (intervention group). All patients were evaluated 6 months after the operation with the Pectus Excavatum Evaluation Questionnaire (PEEQ). RESULTS: There were 16 patients in the control group and 14 in the intervention group. Mean age was 17 (SD: 3.3, range 14-27) years. There were no demographic differences between groups. Two patients in the control group and one in the intervention group were repaired with two bars instead of one. There was one reoperation in each group. There was a significant difference between the pre- and postoperative scores, in both groups, in the patient body image domain (control group: 9.5 to 3; p < 0.01; intervention group 10 to 3; p < 0.01), as well as in the psychosocial domain (control group: 13.5 to 24, p < 0.01; intervention group: 15 to 24, p < 0.01). With regards to the patients' perception of physical difficulties before and after MIRPE, the difference between pre- and postoperative scores was greater in the intervention group (8 to 12, p < 0.01) than in the control group (10 to 11, p = 0.04). The mean length of stay was 4.5 and 5 days in the intervention group and the control group, respectively. CONCLUSION: Our study showed that patients who underwent MIRPE with the newly designed bars and stabilizers had non-inferior outcomes than patients reported in the literature who underwent MIRPE with standard bars and stabilizers. We found slightly better outcomes in patients in the intervention group compared to the control group, but larger studies will be needed to confirm if those differences are statistically significant. LEVEL OF EVIDENCE: II.

A prospective controlled randomized multicenter study to evaluate the severity of compensatory sweating after one-stage bilateral thoracic sympathectomy versus unilateral thoracic sympathectomy in the dominant side.

OBJECTIVE: To evaluate the contribution that unilateral thoracic sympathectomy in dominant side or two-stage bilateral thoracic sympathectomy can have as strategies to reduce the incidence of compensatory sweating after sympathectomy for palmar hyperhidrosis. METHODS: This is a prospective, controlled, randomized multicenter trial of 200 participants with palmar hyperhidrosis, which will be randomized into two arms: (a) one-stage bilateral thoracic sympathectomy (control arm); or (b) unilateral thoracic sympathectomy in dominant side (intervention arm). At six months the participants submitted to unilateral procedure can make the contralateral surgery if they wanted it, creating a third group called two-stage bilateral sympathectomy. Participants will be evaluated for the degree of sweating by the Hyperhidrosis Disease Severity Scale (HDSS) and of quality of life questionnaires. RESULTS: 96 participants out of the 200 proposed have been included so far, with 48 participants randomized to each arm. From the sample 61 (63.5%) are female, with a mean age of 24 (20-32) years. There were exclusive palmar hiperhydrosis in 14 cases (14.5%), palmar and plantar hyperhidrosis in 36 (37.5%) cases, palmar and axillar hyperhidrosis in 12 (12,5%) cases and palmar-axillary-plantar hyperhidrosis in 34 (35,4%) cases. The age at the beginning of the disease was childhood (78%), with mean of time of disease 15 (11-22) years. CONCLUSIONS: If one or both hypothesis: (a) unilateral sympathectomy in dominant hand is a satisfactory treatment; b) two-stage bilateral sympathectomy causes less compensatory sweating than in one stage are confirmed there is a chance that surgical therapy for palmar hyperhidrosis can be changed for better.

Analysis of the Results of Videotoracoscopic Sympathectomy in the Treatment of Hyperhidrosis in Patients 40 Years or Older.

BACKGROUND: Several factors that could influence the efficacy and satisfaction of patients after bilateral thoracic sympathectomy (video-assisted thoracoscopic sympathectomy [VATS]) in the treatment of hyperhidrosis (HH) have been studied, but no studies in the literature have specifically analyzed the effectiveness of treatment and variations in the quality of life of patients aged 40 years or older compared with those of young adult patients (19-40 years). METHODS: We retrospectively analyzed 2,431 HH patients who underwent bilateral VATS and divided the patients into the following groups: a group younger than 40 years old (1,760 patients) and a group 40 years and older (142 patients). Variables included quality of life before surgery, improvement in quality of life after surgery, clinical improvement in sweating, the presence of severe compensatory hyperhidrosis (CH), and general satisfaction at 1 month after surgery. RESULTS: We observed that all surgical patients presented with poor or very poor quality of life before surgery, with similar proportions in both groups. In the postoperative period, we observed improvement in quality of life in more than 90% of the patients, with no significant difference noted between the 2 groups of patients. More than 90% of the patients in this series had great clinical improvement in the main HH site, with no significant difference between the 2 groups. Severe CH occurred in 23.8% of the patients in this series, with no significant difference between the 2 groups. CONCLUSIONS: Patients 40 years of age or older benefit just as much as younger patients from VATS performed to treat primary HH, presenting excellent significant surgical results.

Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments.

OBJECTIVE: Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. METHODS: This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. RESULTS: Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. CONCLUSIONS: In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.

Number of Preoperative Hyperhidrosis Sites Does Not Affect the Sympathectomy Postoperative Results and Compensatory Hyperhidrosis Occurrence.

BACKGROUND: Patients with primary hyperhidrosis present with sweating in two or more sites in nearly 85% of cases. In this study, we examined whether the number of hyperhidrosis sites is related to the surgery outcomes. METHODS: One hundred ninety-three hyperhidrosis patients who underwent bilateral videothoracoscopic sympathectomy after failure or dissatisfaction with clinical treatment were distributed into three groups based on the number of hyperhidrosis sites (one site, two sites, and three or more sites of hyperhidrosis). The primary endpoints in the study were as follows: quality of life prior to surgery, improvement of quality of life after surgery, clinical improvement of sweating, presence or absence of compensatory hyperhidrosis, and general satisfaction after 1 month of surgery. RESULTS: Patients with two or more hyperhidrosis sites had worse quality of life before surgery than patients with a single hyperhidrosis site. There was an improvement in the quality of life in more than 95% of the patients, clinical improvement in more than 95% of patients, severe compensatory hyperhidrosis in less than 10%, and low general satisfaction after 1 month of surgery in only 2.60% of the patients, with no differences among the three groups. CONCLUSIONS: Patients with more than one preoperative hyperhidrosis site present worse quality of life prior to surgery than those with a single hyperhidrosis site, but the number of hyperhidrosis sites before surgery does not affect surgery outcomes.

Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments / De volta para o futuro: série de casos de reparo minimamente invasivo do pectus excavatum com instrumentos comuns

ABSTRACT Objective: Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. Methods: This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. Results: Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. Conclusions: In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.

RESUMO Objetivo: O minimally invasive repair of pectus excavatum (MIRPE, reparo minimamente invasivo do pectus excavatum) é um tratamento cirúrgico do PE. Durante o procedimento, utiliza-se um introdutor específico a fim de criar um túnel mediastinal para a colocação toracoscópica de uma barra metálica. Já houve casos relatados de perfuração cardíaca durante essa etapa arriscada. O introdutor grande pode ser uma perigosa alavanca em mãos inábeis. Propusemo-nos a determinar a segurança e viabilidade do uso de instrumentos comuns (isto é, sem contar com dispositivos ou ferramentas especiais) para criar o túnel retroesternal durante o MIRPE. Métodos: Estudo preliminar sobre o MIRPE with regular instruments (MIRPERI, MIRPE com instrumentos comuns), envolvendo 28 pacientes com PE. Foram registrados dados demográficos básicos dos pacientes, medições torácicas e detalhes cirúrgicos, bem como complicações intra e pós-operatórias. Resultados: Os pacientes submetidos ao MIRPERI apresentavam índice de Haller entre 2,58 e 5,56. Não ocorreram complicações intraoperatórias. As complicações pós-operatórias incluíram náusea/vômito em 8 pacientes, prurido em 2 e tontura em 2, bem como atelectasia, pneumotórax com drenagem torácica, derrame pleural e dispneia em 1 paciente cada. Conclusões: Neste estudo preliminar, a taxa de complicações associadas ao MIRPERI foi comparável à relatada na literatura para o MIRPE. A abordagem de MIRPERI tem o potencial de melhorar a segurança do reparo do PE, particularmente para cirurgiões que não têm acesso a certos instrumentos especiais ou não foram treinados para utilizá-los.

Pulmonary inhalation-perfusion scintigraphy in the evaluation of bronchoscopic treatment of bronchopleural fistula.

OBJECTIVE: To evaluate the use of pulmonary inhalation-perfusion scintigraphy as an alternative method of investigation and follow-up in patients with bronchopleural fistula (BPF). MATERIALS AND METHODS: Nine patients with BPFs were treated through the off-label use of a transcatheter atrial septal defect occluder, placed endoscopically, and were followed with pulmonary inhalation-perfusion scintigraphy, involving inhalation, via a nebulizer, of 900-1300 MBq (25-35 mCi) of technetium-99m-labeled diethylenetriaminepentaacetic acid and single-photon emission computed tomography with a dual-head gamma camera. RESULTS: In two cases, there was a residual air leak that was not identified by bronchoscopy or the methylene blue test but was detected only by pulmonary inhalation-perfusion scintigraphy. Those results correlated with the evolution of the patients, both of whom showed late signs of air leak, which confirmed the scintigraphy findings. In the patients with complete resolution of symptoms and fistula closure seen on bronchoscopy, the scintigraphy was completely negative. In cases of failure to close the BPF, the scintigraphy confirmed the persistence of the air leak. In two patients, scintigraphy was the only method to show residual BPF, the fistula no longer being seen on bronchoscopy. CONCLUSION: We found pulmonary inhalation-perfusion scintigraphy to be a useful tool for identifying a residual BPF, as well as being an alternative method of investigating BPFs and of monitoring the affected patients.

Pulmonary inhalation-perfusion scintigraphy in the evaluation of bronchoscopic treatment of bronchopleural fistula / Cintilografia pulmonar inalatória na avaliação do tratamento broncoscópico de fístula broncopleural

Abstract Objective: To evaluate the use of pulmonary inhalation-perfusion scintigraphy as an alternative method of investigation and follow-up in patients with bronchopleural fistula (BPF). Materials and Methods: Nine patients with BPFs were treated through the off-label use of a transcatheter atrial septal defect occluder, placed endoscopically, and were followed with pulmonary inhalation-perfusion scintigraphy, involving inhalation, via a nebulizer, of 900-1300 MBq (25-35 mCi) of technetium-99m-labeled diethylenetriaminepentaacetic acid and single-photon emission computed tomography with a dual-head gamma camera. Results: In two cases, there was a residual air leak that was not identified by bronchoscopy or the methylene blue test but was detected only by pulmonary inhalation-perfusion scintigraphy. Those results correlated with the evolution of the patients, both of whom showed late signs of air leak, which confirmed the scintigraphy findings. In the patients with complete resolution of symptoms and fistula closure seen on bronchoscopy, the scintigraphy was completely negative. In cases of failure to close the BPF, the scintigraphy confirmed the persistence of the air leak. In two patients, scintigraphy was the only method to show residual BPF, the fistula no longer being seen on bronchoscopy. Conclusion: We found pulmonary inhalation-perfusion scintigraphy to be a useful tool for identifying a residual BPF, as well as being an alternative method of investigating BPFs and of monitoring the affected patients.

Resumo Objetivo: Avaliar a cintilografia por inalação-perfusão pulmonar como método alternativo de investigação e acompanhamento em pacientes com fístula broncopleural (FBP). Materiais e Métodos: Nove pacientes com FBPs foram tratados de forma endoscópica com o uso off label de um oclusor transcateter de defeito do septo interatrial e foram seguidos com cintilografia de inalação-perfusão pulmonar usando tomografia computadorizada por emissão de fóton único com câmera de cintilação de duas cabeças e inalação com 900-1300 MBq (25-35 mCi) de ácido dietilenotriaminopentacético marcado com tecnécio-99m, inserido num nebulizador. Resultados: Broncoscopia e teste de azul de metileno não foram capazes de detectar dois casos de vazamento residual, detectados apenas por cintilografia por inalação-perfusão pulmonar. Esses resultados foram correlacionados com a evolução desses pacientes que tardiamente apresentaram sinais de vazamento de ar confirmando os achados da cintilografia. Pacientes com resolução completa dos sintomas e com aspecto broncoscópico do fechamento da fístula apresentaram cintilografia negativa completa. Em casos de falha no fechamento da FBP, a cintilografia por inalação-perfusão confirmou a persistência da fuga de ar. Em dois pacientes, a cintilografia foi o único método a mostrar FBP residual, apesar da ausência da fístula por avaliação broncoscópica. Conclusão: Neste estudo, a cintilografia de inalação-perfusão pulmonar mostrou ser um instrumento útil para identificar FBP residual e como método alternativo de investigação e seguimento de pacientes com FBPs.

The relation between age and outcomes of thoracic sympathectomy for hyperhidrosis: The older the better.

OBJECTIVE: Several factors may potentially influence the efficacy and patient satisfaction after bilateral thoracic sympathectomy as the treatment for hyperhidrosis, but few studies have specifically analyzed the impact of age on the efficacy of this treatment, the occurrence of compensatory hyperhidrosis (CH), and variations in the quality of life. METHODS: We retrospectively analyzed the effect of age, body mass index, surgical techniques, quality of life before surgery, betterment in the quality of life after surgery, clinical improvement in sweating at the main site, and the occurrence and intensity of CH in patients with hyperhidrosis (n = 1633) who underwent bilateral sympathectomy. RESULTS: Quality of life improved in more than 90% of patients, and severe CH occurred in 5.4%. Age did not affect these outcomes. The older, the greater reduction in sweating, and CH was linked to other variables (body mass index, craniofacial hyperhidrosis, and level of resection). CONCLUSIONS: We observed that patients with old age reported an improvement in sweating in the main site of hyperhidrosis. Sympathectomy outcomes in older patients are similar to those observed in younger patients in terms of quality of life improvement and occurrence of CH.